ALL PROVIDERS

Social Services Law (SSL) §363-d and Part 521, of Title 18 of the New York State Codes, Rules, and Regulations, both entitled Provider Compliance Programs, is being actively enforced by the Office of the Medicaid Inspector General (OMIG) in 2010. This regulation requires that all Medicaid providers who fall under the following categories, certify that they have adopted and implemented an effective compliance program by December 31, 2010:

persons subject to the provisions of Articles 28 or 36 of the New York State Public Health Law;

persons subject to the provisions of Articles 16 or 31 of the New York State Mental Hygiene Law; or

other persons, providers, or affiliates who provide care, services or supplies under the Medicaid program, or persons who submit claims for care, services or supplies for or on behalf of another person or provider for which the Medicaid program is or should be reasonably expected by a provider to be a substantial portion of their business operations.

Under 18 NYCRR §521.2(b), "substantial portion" of business operations is defined as any of the following:

when a person, provider, or affiliate claims or orders, or has claimed or has ordered, or should be reasonably expected to claim or order at least $500,000 in any consecutive 12-month period from the medical assistance program;

when a person, provider, or affiliate receives or has received, or should be reasonably expected to receive at least $500,000 in any consecutive 12-month period directly or indirectly from the medical assistance program; or

when a person, provider, or affiliate who submits or has submitted claims for care, services, or supplies to the medical assistance program on behalf of another person or persons in the aggregate of at least $500,000 in any consecutive 12-month period.

Each compliance program must contain the eight elements required under SSL §363-d and 18 NYCRR §521.3(c). When applying for enrollment in the medical assistance program, and during the month of December each year thereafter, 18 NYCRR §521.3(b) requires that providers certify to the Department of Health and OMIG that a compliance program meeting the requirements of the regulation is in place. The annual deadline each year for providers to certify that they have an effective compliance program is December 31.

The regulation, certification form, and FAQ's are available on the OMIG Website at: http://www.omig.ny.gov. Under the "Compliance" tab on OMIG's home page click on "Provider Compliance" to access this information. Questions? Please contact the Bureau of Compliance at (518)
402-1116.

Effective October 1, 2010, managed care enrollment will be required for most Medicaid beneficiaries
residing in Cayuga, Essex, Hamilton, Madison, Schoharie, Tompkins, and Wayne Counties.
Once a mandatory managed care program is implemented in a county, it is expected that the enrollment of
all eligible Medicaid beneficiaries will take up to 18 months to complete.

Providers should check the Medicaid Eligibility Verification System (MEVS) prior to rendering services
to determine Medicaid eligibility and the conditions of Medicaid coverage. Providers are strongly
encouraged to check eligibility at each visit as eligibility and enrollment status may change at any
time. If the Medicaid beneficiary is enrolled in a Medicaid managed care plan, the first coverage
message will indicate "Managed Care Coordinator" or "Eligible PCP" (depending on the device used).

MEVS will identify the scope of benefits a Medicaid beneficiary's Medicaid managed care organization provides through specific coverage codes. When using a touch-tone telephone you will hear the "Description" of each covered service. When using either the Point of Service (POS) or ePACES the "coverage codes" will be displayed. If the message "All" appears, all services will be covered.

Medicaid will not reimburse a provider on a fee-for-service basis if MEVS indicates that the service is
covered by the plan.

Providers may call the eMedNY Call Center at (800) 343-9000 with any Medicaid billing issues.
Medicaid beneficiaries may contact their local department of social services to learn more about
managed care.

Most Medicaid beneficiaries residing in Lewis and Wyoming counties now have the option to enroll in Medicaid Managed Care. New York State Catholic Health Plan (Fidelis) is now available in these counties for both Medicaid Managed Care and Family Health Plus.

Providers should check the Medicaid Eligibility Verification System (MEVS) prior to rendering services to determine Medicaid eligibility and the conditions of Medicaid coverage. Providers are strongly encouraged to check eligibility at each visit as eligibility and enrollment status may change at any time. If the Medicaid beneficiary is enrolled in a Medicaid managed care plan, the first coverage message will indicate "Managed Care Coordinator" or "Eligible PCP" (depending on the device used). If they are enrolled in a Family Health Plus (FHP) plan, the first coverage message will indicate "Family Health Plus."

MEVS will identify the scope of benefits a Medicaid beneficiary's Medicaid Managed Care Organization provides through specific coverage codes. When using a touch-tone telephone you will hear the "Description" of each covered service. When using either the Point of Service (POS) or ePACES the "Coverage Codes" will be displayed. If the message "All" appears, all services will be covered.

Medicaid will not reimburse a provider on a fee-for-service basis if MEVS indicates that the service is covered by the plan.

Providers may call the eMedNY Call Center at (800) 343-9000 with any Medicaid billing issues. Medicaid beneficiaries should contact their local department of social services to learn more about managed care.

The Centers for Medicare and Medicaid Services (CMS), recently approved additional procedures considered to be family planning related and are covered for enrollees in FPBP. These procedures are considered family planning when provided during a family planning visit or during a follow-up visit when the procedure is related to the initial family planning visit.

99050 Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service.

99051 Service(s) provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service.

A number of nursing home administrators have inquired as to whether Medicaid residents or their families may be charged a fee when a nursing home staff member accompanies a resident to and from medical appointments outside the facility. Example: Nursing home personnel travel with a resident to a medical appointment to provide necessary personal care services or ensure effective communication between residents and practitioners. Nursing homes are prohibited from seeking monetary compensation from Medicaid residents or their family members.

The fee-for-service reimbursement paid by Medicaid to transportation and medical providers is considered payment in full for all services rendered to the beneficiary both during transit and at the medical appointment. No additional compensation should be sought or accepted.

Effective December 1, 2010, only certain hospitals will be permitted to provide surgical services to Medicaid fee-for-service beneficiaries requiring bariatric surgery. Section 21, Part E, Chapter 63 of the Laws of 2005 gives the Commissioner of Health the authority to negotiate rates of payment for specialty inpatient services provided to Medicaid fee-for-service beneficiaries in designated areas of the State. Bariatric surgery was selected as one of the specialty services and New York City as one of the service areas. The following five hospitals were selected and will be designated by the NYS Department of Health as Bariatric Specialty Centers:

New York City Hospitals:

Harlem Hospital Center (Manhattan)

St. Luke's Roosevelt (Manhattan)

Brookdale Medical Center (Brooklyn)

Lutheran Medical Center (Brooklyn)

Montefiore Medical Center (Bronx)

Effective December 1, 2010, only these NYC hospitals will be reimbursed for bariatric surgical services for Medicaid fee-for-service recipients.

Also effective December 1, 2010, only non-NYC hospitals that meet Center for Medicare and Medicaid Services' (CMS) minimum facility standards and are designated either by the American College of Surgeons and/or the American Society for Metabolic and Bariatric Surgery as a Medicare Approved Facility for Bariatric Surgery, will be reimbursed for bariatric surgical services for Medicaid fee-for-service beneficiaries. As of October 2010, the following hospitals have this designation:

New York Medicaid will reimburse enrolled office-based practitioners, pharmacies, and Article 28 clinic providers for the cost of the seasonal flu and pneumococcal vaccines and for the administration of these vaccines. The fee-for-service coverage policies and billing rules for seasonal flu and pneumococcal vaccines have been specifically designed to facilitate improved access to these vaccines and are outlined as follows:

Medicaid will cover the cost of seasonal flu and pneumococcal vaccines and the administration of these vaccines.

Administration of seasonal flu and pneumococcal vaccines may be provided in Article 28 clinic settings; in a practitioner's office by a physician, physician's assistant, nurse practitioner, licensed midwife, registered nurse or licensed practical nurse; or, for ages 18 and older, in a pharmacy by certified pharmacists (within their respective scopes of practice under the State Education Law).

Fee-For-Service Billing Instructions for Article 28 Clinics

When provided in an Article 28 hospital outpatient department or free-standing diagnostic and treatment center clinics (including school based health centers, county health department clinics, Federally Qualified Health Centers and part time clinics), seasonal flu and pneumococcal vaccine administration charges and vaccine charges, if applicable, must be billed as an ordered ambulatory service. These services should NOT be billed as a clinic visit or as part of a clinic visit. Hospital-based clinics are category of service code 0282 and free-standing diagnostic and treatment clinics are category of service code 0163 to denote an ordered ambulatory service other than lab when submitting claims for vaccine administration and vaccine. If these services can be covered by Medicare or another third party insurance coverage, such benefits must be exhausted prior to billing Medicaid.

Seasonal flu and pneumococcal vaccines are billable to Medicaid at their actual acquisition costs for persons aged 19 and older. These vaccines are not billable to Medicaid for those under age 19 as they are provided free of charge through the Vaccines for Children Program. Fees for administration of the seasonal flu and pneumococcal vaccine for each age group and instructions for billing are provided in the chart below.

Medicaid Article 28 Clinic FFS Billing Chart

Immunization Type

Code For Vaccine

Code for Administration

Medicaid Reimbursement for Vaccine

Medicaid Reimbursement for Administration

Vaccine for Children Program (VFC)

Age 19 and older

Up to Age 19

Seasonal Flu

90655
90656
90657
90658
90660

G0008 for intramuscular administration

90473 for intranasal or oral administration

Actual Acquisition Cost

$13.23

$8.57

Enhanced administration fee of $17.85
Bill vaccine procedure code as an ordered ambulatory service and append with "SL" modifier (do not bill an administration code)

Pneumococcal

9066990732

G0009 for intramuscular administration

Same as Above

$13.23

Same as Above

Fee-For-Service Billing Instructions for Office-Based Practitioners

When provided in a practitioner's office as a standalone service or as part of an evaluation and management visit, vaccine administration charges and vaccine charges, if applicable, must be billed using the Medicaid fee schedule. Seasonal flu and pneumococcal vaccines are billable to Medicaid at their actual acquisition costs for persons aged 19 and older. If these services can be covered by Medicare or another third party insurance coverage, such benefits must be exhausted prior to billing Medicaid.

These vaccines are not billable to Medicaid for those under age 19 as they are provided free of charge through the Vaccines for Children Program. Fees for administration of the seasonal flu and pneumococcal vaccines for those 19 and older and those under age 19 are provided in the chart below. The chart also outlines vaccine procedure codes, vaccine specific administration codes, and Medicaid reimbursement for the vaccines and their administration.

Medicaid Office-Based Practitioner FFS Billing Chart

Immunization Type

Code For Vaccine

Code for Administration

Medicaid Reimbursement for Vaccine

Medicaid Reimbursement for Administration (Amount varies based on billing provider)

Vaccine for Children Program (VFC)

Age 19 and older

Up to Age 19

Seasonal Flu

90655
90656
90657
90658

90660

G0008 for intramuscular administration

90473 for intranasal or oral administration

Actual Acquisition Cost

$13.23 - physician$11.25 - nurse practitioner or licensed midwife

$8.57 - physician $7.28 - nurse practitioner or licensed midwife

Enhanced administration fee of $17.85
Bill vaccine procedure code as an ordered ambulatory service and append with "SL" modifier (do not bill an administration code)

Since September 1, 2008, New York Medicaid has required the submission of the Prescriber National Provider Identifier (NPI).
Effective December 2, 2010, New York Medicaid will implement claims editing to enforce the submission of the Prescriber's NPI with pharmacy claims.

Pharmacists:

Beginning December 2, 2010, all pharmacy claims should include the Prescriber NPI in the Prescriber ID field (411-DB) and a "01" in the Provider ID Qualifier field (465-EY). Pharmacy claims submitted with a prescriber's MMIS Provider ID number or profession code and license number will be denied for edit 02029 - "Missing Prescribing NPI."

Prescribers:

The NPI number is currently being imprinted on prescription pads for practitioners who have provided their NPI number to the New York State Official Prescription Program. If the number has already been provided, it will be listed in the online 'profile.'

Practitioners may send an e-mail to: narcotic@health.state.ny.us and provide their NPI number to the New York State Official Prescription Program. Please include the name, state license number and NPI number in the e-mail. The NPI number will also be requested during the registration process.

NOTE: While providing a NPI to the prescription program is optional, doing so will ensure that the dispensing pharmacy can efficiently meet claims submission requirements.

Alternatively, a practitioner may write or stamp their NPI number on the official prescription.

For practitioners who wish to obtain a NPI number, please contact the NPI registry at
(800) 465-3203 or visit:

The administration of select vaccines by qualified pharmacists employed by, or under contract with, Medicaid enrolled pharmacies is reimbursable under the New York Medicaid program. Administration of vaccines is conducted pursuant to NYS Education Law and regulations (8NYCRR63.9) which permits licensed pharmacists who obtain additional certification to administer influenza and pneumococcal vaccinations to adults 18 years of age and older.

The following conditions apply:

Only Medicaid enrolled pharmacies that employ or contract with NYS certified pharmacists to administer vaccines will receive reimbursement for immunization services and products. Each pharmacist certified to administer immunizations will receive a new registration certificate that will contain the prefix "I". Pharmacy interns cannot administer immunizations in New York State.

This information only applies to Medicaid fee-for-service beneficiaries. Medicaid Managed Care and Family Health Plus beneficiaries continue to access immunization services through their health plans. Pharmacists should check with the beneficiary's health plan before immunizing to determine the health plan's coverage policy regarding immunizations provided by pharmacists.

Reimbursement is based on a patient specific or non-patient specific order. These orders must be kept on file at the pharmacy. The ordering prescriber's NPI is required on the claim for the claim to be paid.

Consistent with Medicaid immunization policy for practitioners, pharmacies bill the administration and cost of the vaccine using the following procedure codes. Please note that NDCs are not to be used for billing the vaccine product. Reimbursement for the product will be made at no more than the actual acquisition cost to the pharmacy. No dispensing fee or enrollee co-payment applies. Pharmacies will bill with a quantity of "1" and a day supply of "1".

The Seasonal Flu vaccine and Pneumococcal vaccine for individuals under the age of 19 are provided free of charge by the Vaccines for Children (VFC) program. Therefore, Medicaid will not reimburse providers for these vaccines for individuals under the age of 19. For VFC enrollment information, please visit:
http://nyhealth.gov/prevention/immunization/vaccines_for_children.htm.

The following chart describes the codes and fees that are reimbursable to pharmacies.

Immunization Type

Code For Vaccine

Code for Administration

Medicaid Reimbursement for Vaccine

Medicaid Reimbursement for Administration (Amount varies based on billing provider)

Claims submitted by 340B providers with a "5" in the NCPDP Dispense as Written/Product Selection Code Field (408-D8) AND a "9" in the NCPDP Basis of Cost Determination Field (423-DN) will bypass any of the prior authorization requirements associated with the Preferred Drug and Mandatory Generic Drug Programs. When using these options, the 340B price must be billed to the

Effective October 21, 2010, pharmacies that use a multi-source brand name drug as their most cost-effective option will be able to use a "5" in the NCPDP Dispense as Written/Product Selection Code Field (408-D8) to receive generic drug reimbursement, including the application of generic drug dispensing fee and copayment.

Note: When dispensing a multi-source brand name drug included in the Brand Less Expensive than Generic Program, the claim does not require a "5" in the NCPDP Dispense as Written/Product Selection Code Field (408-D8). Reimbursement for these drugs does not require submission of a particular "DAW" code. However, the appropriate "DAW" code should be used to accurately denote whether the prescriber indicated "Dispense as Written" on the prescription.

The following is a list of the 2011 Medicare Prescription Drug Plans available at no cost to individuals with both Medicare and New York State Medicaid. Other plans offered by these companies may require an additional monthly premium payment. Enrollment for the 2011 benefit year begins November 15, 2010. Contact information was updated in October 2010.

By providing counseling, pharmacotherapy, and referrals, you can double your patients' chances of successfully quitting. For more information, please visit www.talktoyourpatients.org or call the NY State Smokers' Quitline at 1-866-NY-QUITS (1-866-697-8487).

Please Call: 1-877-87FRAUD or (212 417-4570)

You can also complete a Complaint Form online at:

Office of the Medicaid Inspector General: http://www.omig.state.ny.us or call (518) 473-3782 with general
inquiries or 1-877-87FRAUD with suspected fraud complaints or allegations. This contact information can also be used for Provider Self-Disclosures.